Many health care providers, including small and medium-sized physician practices, rely on a number of third party service providers to serve their patients and run their businesses. Perhaps the most important of these is a practice’s electronic medical record (EMR) provider, which manages and stores patient protected health information. EMR providers generally are business associates under HIPAA, subjecting them to many of the same requirements under the HIPAA privacy and security rules applicable to covered healthcare providers. HIPAA-covered healthcare providers should not assume their EMR providers comply with HIPAA and HITECH.

According to a federal Office for Civil Rights (OCR) press release, Medical Informatics Engineering, Inc. (MIE) has paid $100,000 to OCR and has agreed to a detailed corrective action plan to settle potential violations of the HIPAA privacy and security rules. MIE provides software and EMR services to healthcare providers.

According to reporting by the Chicago Tribune,

about 82 percent of hospital information security leaders surveyed reported having a “significant security incident” in the last 12 months, according to the 2019 Healthcare Information and Management Systems Society Cybersecurity Survey.

Yet, according to the same report, spending on information security only takes up about 5% of healthcare providers’ data security budgets, which is well below industry average. Additionally, some have estimated that in 2018, 20% of the breaches suffered by healthcare providers was caused by their third-party service providers. An excellent article by HIPAAJournal outlines a number of statistics illustrating the growing data security risk in healthcare.

In 2015, MIE reported to OCR that it discovered a breach which compromised user IDs and passwords enabling access to electronic protected health information (ePHI) of approximately 3.5 million people. OCR claims that, according to OCR’s investigation, MIE did not conduct a comprehensive risk analysis prior to the breach. The HIPAA rules require entities to perform an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of an entity’s ePHI. This is a basic requirement in the HIPAA security rules that all covered entities and business associates need to perform.

OCR Director Roger Severino noted,

The failure to identify potential risks and vulnerabilities to ePHI opens the door to breaches and violates HIPAA.

So, what is a healthcare provider to do?

A required element of HIPAA compliance includes having business associate agreements in place with business associates, including EMR providers. Under these agreements, business associate agree that they have satisfied the risk assessment requirement under HIPAA. However, in addition to making sure that compliant agreements are in place, covered healthcare providers may want to go a step further. That is, they may want to better assess the compliance efforts of their vendors as represented in the business associate agreement, particularly for those vendors that process and maintain so much of their patients’ ePHI. Providers might, for example, require such vendors to complete a detailed questionnaire about their data security practices, visit the vendor’s facilities, and/or request to review a copy of the vendor’s risk assessment. Similar practices can be applied to all vendors, not just EMR providers or business associates, based on the risk they pose.

Of course, healthcare providers should make sure they themselves are in compliance with the HIPAA privacy and security rules. This includes, among other things, conducting and documenting their own risk assessment. Simply having a set of policies and procedures is not sufficient.

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Photo of Joseph J. Lazzarotti Joseph J. Lazzarotti

Joseph J. Lazzarotti is a principal in the Berkeley Heights, New Jersey, office of Jackson Lewis P.C. He founded and currently co-leads the firm’s Privacy, Data and Cybersecurity practice group, edits the firm’s Privacy Blog, and is a Certified Information Privacy Professional (CIPP)…

Joseph J. Lazzarotti is a principal in the Berkeley Heights, New Jersey, office of Jackson Lewis P.C. He founded and currently co-leads the firm’s Privacy, Data and Cybersecurity practice group, edits the firm’s Privacy Blog, and is a Certified Information Privacy Professional (CIPP) with the International Association of Privacy Professionals. Trained as an employee benefits lawyer, focused on compliance, Joe also is a member of the firm’s Employee Benefits practice group.

In short, his practice focuses on the matrix of laws governing the privacy, security, and management of data, as well as the impact and regulation of social media. He also counsels companies on compliance, fiduciary, taxation, and administrative matters with respect to employee benefit plans.

Privacy and cybersecurity experience – Joe counsels multinational, national and regional companies in all industries on the broad array of laws, regulations, best practices, and preventive safeguards. The following are examples of areas of focus in his practice:

  • Advising health care providers, business associates, and group health plan sponsors concerning HIPAA/HITECH compliance, including risk assessments, policies and procedures, incident response plan development, vendor assessment and management programs, and training.
  • Coached hundreds of companies through the investigation, remediation, notification, and overall response to data breaches of all kinds – PHI, PII, payment card, etc.
  • Helping organizations address questions about the application, implementation, and overall compliance with European Union’s General Data Protection Regulation (GDPR) and, in particular, its implications in the U.S., together with preparing for the California Consumer Privacy Act.
  • Working with organizations to develop and implement video, audio, and data-driven monitoring and surveillance programs. For instance, in the transportation and related industries, Joe has worked with numerous clients on fleet management programs involving the use of telematics, dash-cams, event data recorders (EDR), and related technologies. He also has advised many clients in the use of biometrics including with regard to consent, data security, and retention issues under BIPA and other laws.
  • Assisting clients with growing state data security mandates to safeguard personal information, including steering clients through detailed risk assessments and converting those assessments into practical “best practice” risk management solutions, including written information security programs (WISPs). Related work includes compliance advice concerning FTC Act, Regulation S-P, GLBA, and New York Reg. 500.
  • Advising clients about best practices for electronic communications, including in social media, as well as when communicating under a “bring your own device” (BYOD) or “company owned personally enabled device” (COPE) environment.
  • Conducting various levels of privacy and data security training for executives and employees
  • Supports organizations through mergers, acquisitions, and reorganizations with regard to the handling of employee and customer data, and the safeguarding of that data during the transaction.
  • Representing organizations in matters involving inquiries into privacy and data security compliance before federal and state agencies including the HHS Office of Civil Rights, Federal Trade Commission, and various state Attorneys General.

Benefits counseling experience – Joe’s work in the benefits counseling area covers many areas of employee benefits law. Below are some examples of that work:

  • As part of the Firm’s Health Care Reform Team, he advises employers and plan sponsors regarding the establishment, administration and operation of fully insured and self-funded health and welfare plans to comply with ERISA, IRC, ACA/PPACA, HIPAA, COBRA, ADA, GINA, and other related laws.
  • Guiding clients through the selection of plan service providers, along with negotiating service agreements with vendors to address plan compliance and operations, while leveraging data security experience to ensure plan data is safeguarded.
  • Counsels plan sponsors on day-to-day compliance and administrative issues affecting plans.
  • Assists in the design and drafting of benefit plan documents, including severance and fringe benefit plans.
  • Advises plan sponsors concerning employee benefit plan operation, administration and correcting errors in operation.

Joe speaks and writes regularly on current employee benefits and data privacy and cybersecurity topics and his work has been published in leading business and legal journals and media outlets, such as The Washington Post, Inside Counsel, Bloomberg, The National Law Journal, Financial Times, Business Insurance, HR Magazine and NPR, as well as the ABA Journal, The American Lawyer, Law360, Bender’s Labor and Employment Bulletin, the Australian Privacy Law Bulletin and the Privacy, and Data Security Law Journal.

Joe served as a judicial law clerk for the Honorable Laura Denvir Stith on the Missouri Court of Appeals.